sustaining community-based prevention in rural settings
BOX 4.2 STEPS FOR PLANNING, IMPLEMENTING AND SUSTAINING COMMUNITY-BASED PREVENTION PROGRAMMES
Assess
• Needs (substance use, factors contributing to it, existing prevention response and related service structures and the gaps in them)
• Resources (capacities, infrastructures, frameworks, financial resources)
• Community readiness
Mobilize and organize
• Identify and engage “champions” and stakeholders to be involved in the planning and imple- mentation process
• Build capacity
• Mobilize and build support in the wider community
Plan
• Identify priorities, goals, vision
• Plan logical and structured prevention programmes based on the assessment and existing evidence about what works, e.g., via logic model exercise
• Adapt programmes
• Plan monitoring and evaluation, possibly using the data from the assessment as your baseline data for assessing the change in substance use and related factors
• Build capacity
Implement
Evaluate
• Monitor and evaluate process
• Evaluate effectiveness
4.4.1 Mobilizing, organizing, and
empowering community stakeholders
The guidelines for system-level assessment discussed in chapter 2, together with the ecological model, provide a framework for identifying community stakeholders and leaders. The process should be representative and inclusive, ensuring participation of community organizations and leaders across key community sectors, institutions and groups. Key participants should include schools, the health-care system, local government, faith-based organizations and other community organizations. Engaging them as partners throughout the process to assess and iden- tify priority problems and resources, and to select, adapt and implement the most suitable prevention strategies, can help generate community buy-in and support for the initiative. In addition, this participa- tion can support planning for prevention strategies most relevant to the needs of the community, as well as to ensure the quality of implementation and the sustainability of the activities. Often, a key group is engaged as a project partner to actually carry out the assessment, planning, implementation and evaluation processes. The wider community is mobilized to inform, participate in and support these prevention efforts. Once the process has achieved evidence of reductions in substance use due to prevention initia- tives, disseminating the results can help to generate further support for the prevention activities. Identify- ing, mobilizing and organizing the key stakeholders is closely tied to the process of assessing community needs, priorities and resources, as discussed next.
4.4.2 Assessing and identifying
readiness, needs and resources
The system- and national-level assessment, discussed in chapter 2, as well as the ecological model discussed earlier in this chapter, provide a context and tools for
125 The United Nations Guiding Principles on Alternative Development provide a useful reference document for such approaches, United Nations General Assembly Resolution A/RES/68/196 Available at https://www.unodc.org/documents/commissions/CND/Drug_Resolutions/2010- 2019/2013/A_RES_68_196.pdf.
identifying substance use-related needs, possibilities and resources in rural settings. Assessing substance use, the factors contributing to it, as well as existing prevention programmes and gaps in their quality and coverage, provides a good starting point for planning a programme tailored to the specific needs of the given community. When conducting a participatory process to assess the most crucial factors contribut- ing to substance use in a given community, it is important to highlight the benefits of grounding the assessment and the planning based on it on empirical evidence and scientific literature, rather than on common sense or traditional values. Assessing the resources in the community includes taking inven- tory of the stakeholders, professional capacities in different fields of prevention, infrastructures such as those in education, health care or social work that could be utilized, as well as financial resources. Finally, understanding community readiness to address substance use is key to selecting appropriate prevention strategies for the given community, or in some cases deciding that there are other priorities beyond prevention. An example could be a com- munity in a drug production area where alternative development could be an appropriate approach.125
When people accessing resources critical for pre- vention are not on board, it is important to focus on ways to increase their level of readiness to engage in prevention planning.
This step of assessing needs, resources and readiness is a multi-stage process, which typically includes the following elements:
• Assessing substance use and related problems
(this might include prevalence in different sub- populations, in different locations, initiation age, transition to disorders, types of substances used, patterns of use (frequency, dosage, mode of administration), hot spots of use, risk groups and trends over time))
Assessing the consequences of substance use (such as morbidity, communicable diseases such as HIV, mortality, unemployment, lost productivity, crime, foster care and other related costs)
• Assessing factors contributing to the problem
behaviours (the “risk and protective factors”)
• Assessing existing prevention response and gaps in
it, and in existing regulatory frameworks (e.g., poli- cies regarding tobacco and alcohol or prevention education in schools)
• Assessing resources (such as identifying key com-
munity stakeholders, available trained workforce and expertise on different topics, financial resources, possible infrastructures to be engaged, equipment)
• Assessing community readiness (by interviewing
key respondents and community leaders)
• Building strategies based on community needs,
possibilities and readiness
• Building capacities, conducting training sessions
Assessing community readiness is a crucial part of this process, and one of the first steps that need to be taken to effectively create change. Based on the assessment, capacity can be built to increase the readiness, and strategies with the best fit to the community’s current stage can be identified. Assessing community readi- ness can in itself be defined as a multi-step process to identify the capacity of a community to implement programmes, policies and other changes, including:126
• Identification of the issue • Defining the community
• Conducting key respondent/community leader
interviews
• Score in the interviews to determine levels of
readiness
126 Indiana Prevention Resource Center. Community Readiness. Available: http://www.drugs.indiana.edu/spf/docs/Comparison%20of%20 Community%20Readiness%20Assessment%20Tools.pdf. Downloaded: September 22, 2016.
127 Substance Abuse and Mental Health Service Administration’s Center for the Application of Prevention Technologies. “Tools to Assess Community Readiness to Prevent Substance Misuse”, Available: http://www.samhsa.gov/capt/sites/default/files/resources/community-readiness-. tools.pdf. Downloaded: September 22, 2016.
Develop strategies based on level of readiness
• Conduct trainings and build community readiness
as needed
Many tools, ranging from relatively simple assess- ments suitable for low-resource environments to more complicated, survey-based tools, are available for assessing community readiness.127
In conducting these assessments, it is essential that local community leaders and stakeholders be engaged in a process to improve local participation, address local contextual and cultural factors, and enhance community buy-in. This is another oppor- tunity in which the social ecological model can provide guidance in identifying the key community leaders. The key leaders to be interviewed from the com munity might entail people from the following sectors and institutions:
• Law enforcement • School
• Community members at large • Social services
• Medical representatives • City/tribal government • Spiritual/religious community • Mental health
The interviews might seek to gather information, for example, on the following topics:
• Existing prevention-related efforts (programmes,
activities, policies, etc.)
• Knowledge in the community about such efforts • Who the leaders specific to this issue in your com-
• What the community climate is like, especially
relating to substance use
• How knowledgeable community members are
about this issue
• What resources might exist for prevention efforts
There are many developed instruments available for conducting key respondent/community leader inter- views, including tools developed by the Community Partners Institute128 and the community report tool
developed by the Indiana Prevention Resource Center129 that can be modified for different rural set-
tings and that provides a useful structure and tem- plate for such assessments. Resources to support the assessment of the substance use situation and the related risk/protective factors include a set of stand- ardized indicators used in global surveys,130 or the
EMCDDA Instrument Bank131 may be useful. Utiliz-
ing data available from different data sources (such as international or national surveys, health-care, or law enforcement registries) and combining different types of data (qualitative and quantitative) allows the assessment team to strategically collect new data to supplement existing data and form a comprehensive picture of the situation while optimizing the use of resources. Quality assessment is necessary to develop a culturally-relevant community-level prevention plan.132,133 Completion of this community-level
assessment process typically requires guidance from assessment and prevention experts, and community stakeholders may find it difficult to conduct the assessment without external guidance and resources.
128 Community Partners Institute. Tri-Ethnic Center for Prevention Research. “How to Use Community Readiness Interviews”, available: (http://www.drugs.indiana.edu/spf/docs/TriEthnicCRS_combined.doc. Downloaded: September 22, 2016.
129 Indiana Prevention Resource Center. “Community Resource Guide Template”, available: http://www.drugs.indiana.edu/spf/docs/Commu- nity%20Resource%20Assessment%20Template%20(Updated%20FY15).docx. Downloaded: September 22, 2016.
130 Such as Health Behaviour of School Children (www.hbsc.org) or the Global school-based student health survey (www.who.int/chp/gshs/en/) 131 http://www.emcdda.europa.eu/eib
132 Community Partners Institute. Tri-Ethnic Center for Prevention Research. “How to Use Community Readiness Interviews”, available: http://www.drugs.indiana.edu/spf/docs/TriEthnicCRS_combined.doc. Downloaded: September 22, 2016.
133 Indiana Prevention Resource Center. “Community Resource Guide Template”, available: http://www.drugs.indiana.edu/spf/docs/ Community%20Resource%20Assessment%20Template%20(Updated%20FY15).docx. Downloaded: September 22, 2016.
134 Substance Abuse and Mental Health Service Administration, Center for the Application of Prevention Technologies. Available: http://www.samhsa.gov/capt/applying-strategic-prevention-framework/step3-plan/building-logic-models. Downloaded: September 22, 2016.
This provides an opportunity for national-level stake- holders to engage with local community leaders.
4.4.3 Creating an action plan
and building capacities
Creating an effective action plan requires:
1. An understanding of the issues and problems impacting the community (the assessment process);
2. An agreed upon list of the priority issues (determined by community members); and 3. A clear understanding of how proposed inter-
vention strategies will address the priority issues (programme theory of change). This last element is important and is often an overlooked component of prevention planning.
Programme logic models provide a useful tool for thinking through this process, and the United States Substance Abuse and Mental Health Service Admin- istration (SAMHSA) provides a useful sample for cre- ating one.134 A process to select prevention strategies
that explicitly target the identified priority substance use issues requires establishing connections between:
• Problems identified by communities
• Community-specific risk and protective factors
• Planned interventions that build on the resources
and opportunities identified in the community
• Anticipated short- and long-term changes of the
planned interventions that address prioritized contributing factors
The logic modelling process can help to identify gaps in reasoning, potential mismatches between pro- gramme plans and desired outcomes, programmatic bottlenecks that may inhibit implementation, and needed resources, and provides a substantial start to the action plan. Connecting programme activity to well-defined outcomes is an important step for evaluating programme success.
The additional elements needed to complete the action plan include the specific action steps necessary to implement and operate the planned prevention strate- gies, staffing issues (who will undertake specific action/ implementation steps), required financial re sources, and any external training or technical assistance needed by the communities. This is an area where national- level entities, NGOs and/or academic organizations can play an important technical assistance role to help communities. The provision of resources, staffing and technical assistance to support this community-based process, which may include capacity-building opportu- nities and making evidence-based programmes availa- ble in a meaningful way, is essential. Capacity-building is further discussed in case study of chapter 4.4.5 .